When assessing a child after heart surgery to correct Tetralogy of Fallot (TOP) which finding should alert the nurse to suspect a le carat output?
Altered level of consciousness and treaty pulse
Bounding pulses and mottled skin
Capillary refill of 2 seconds and blood pressure of 96/47 mmHg
Extremities warm to the touch and pale skin
The Correct Answer is A
A.Altered level of consciousness and thready pulse.
In a child after heart surgery to correct Tetralogy of Fallot (TOF), a thready pulse and altered level of consciousness can be indicative of poor cardiac output. This may suggest that the heart is not effectively pumping blood to meet the body's needs.
B. Bounding pulses and mottled skin: Bounding pulses and mottled skin are not typical signs of decreased cardiac output. Bounding pulses are often associated with increased cardiac output.
C. Capillary refill of 2 seconds and blood pressure of 96/47 mmHg: A capillary refill of 2 seconds is within the normal range, and a blood pressure of 96/47 mmHg is reasonable for a child. These findings do not necessarily indicate poor cardiac output.
D. Extremities warm to the touch and pale skin: Warm extremities and pale skin are not typical signs of decreased cardiac output. Cold extremities and cyanosis may be more concerning signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "That big soft spot will be covered in bone by the end of the second month" is not accurate. The closure usually occurs later than the second month.
B. "The big soft spot will close at around 24 months of age" is an overestimation of the typical closure time. It is usually closed earlier than 24 months.
C. "The big soft spot is usually closed between 12 and 18 months of age."
The anterior fontanel is the soft spot located on the baby's head, and its closure is a natural part of an infant's development. The timing of closure can vary from one child to another. However, the typical range for the closure of the anterior fontanel is between 12 and 18 months of age. This information provides a general guideline for parents while acknowledging the natural variability in child development.
D. "Babies' soft spots close at different times depending on their growth rate" is true to some extent, but providing a general range (option C) is more informative for parents.
Correct Answer is C
Explanation
A. Lordosis: Lordosis is an excessive inward curvature of the spine, typically seen in the lower back. It is often referred to as "swayback."
B. Torticollis: Torticollis is a condition where the head is tilted to one side and may be rotated to the opposite side. It typically affects the neck muscles and is not related to lateral curvature of the spine.
C. Scoliosis.
Scoliosis is a lateral curvature of the spine. It is characterized by an abnormal sideways curvature of the spine, which can lead to an "S" or "C" shape of the spine. Scoliosis can occur during adolescence, and routine physical examinations may reveal this condition.
D. Kyphosis: Kyphosis is an excessive outward curvature of the spine, which can result in a rounded or hunched back, often seen in the upper back or thoracic spine.
In summary, the lateral curvature of the spine observed in this adolescent should be documented as scoliosis.
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